Methods of detecting and treating pulmonary hypertension

ABSTRACT

The present disclosure describes a method of quantifying amounts of phosphopeptides using isotopically-enriched peptides as internal standards. A kit comprising at least one isotopically-enriched phosphorylated peptide can be used to quantify changes in amounts of phosphopeptides using parallel reaction monitoring mass spectrometry techniques. The invention can be used to indicate the pathologic mechanism, severity of the disease, and treatment response of a subject. The invention can also be used to identify subjects who require more aggressive therapeutic interventions or alternative treatments.

CROSS REFERENCE

This Application claims the benefit of U.S. Provisional Application No. 62/253,184, filed Nov. 10, 2015, the contents of which is incorporated herein by reference in its entirety.

GOVERNMENT RIGHTS

The invention was made with government support under R03HL110821 awarded by the National Heart, Lung, and Blood Institute (NHLBI). The government has certain rights in the invention.

BACKGROUND

Pulmonary hypertension (PH) is a rare disorder of the pulmonary vasculature that is associated with high morbidity and mortality. The pathology of the disease includes plexiform lesions of disorganized angiogenesis and abnormal neointimal cellular proliferation, which obstruct blood flow through the pulmonary arterioles. Phosphorylation patterns of proteins occur at various stages of PH.

INCORPORATION BY REFERENCE

Each patent, publication, and non-patent literature cited in the application is hereby incorporated by reference in its entirety as if each was incorporated by reference individually.

SUMMARY OF THE INVENTION

In some embodiments, the invention provides a method comprising: a) adding to a sample of a protein extracted from a buffy coat an amount of a quantification standard to provide a test sample; and b) assaying the test sample to quantify in the test sample a wild type phosphopeptide of the protein extracted from the buffy coat, wherein the quantifying is based on the amount of the quantification standard, wherein the quantification standard is a form of the phosphopeptide that is isotopically enriched to a non-natural abundance of an isotope.

In some embodiments, the invention provides a chemical aliquot comprising a sample of a phosphopeptide, wherein at least 1% of the sample of the phosphopeptide consists of molecules that have an amino acid residue that has at least two ¹³C nuclei, wherein the sample contains at least 1 pg of the phosphopeptide, wherein the phosphopeptide has at least 90% sequence identity to any compound of any of TABLE 2 or TABLE 3.

In some embodiments, the invention provides a kit comprising: a) a chemical aliquot comprising a sample of a phosphopeptide, wherein at least 1% of the sample of the phosphopeptide consists of molecules that have an amino acid residue that has at least two ¹³C nuclei, wherein the sample contains at least 1 pg of the phosphopeptide, wherein the phosphopeptide has at least 90% sequence identity to any compound of any of TABLE 2 or TABLE 3; and b) an additional aliquot comprising a sample of the phosphopeptide that has nuclei in a natural abundance of isotopes.

BRIEF DESCRIPTION OF THE FIGURES

FIG. 1 shows western blots with phospho-specific and total IKZF3 antibodies.

FIG. 2 shows immunohistochemistry results using a pIKZF3 antibody.

FIG. 3 shows immunohistochemistry of iPAH lung tissue and depicts inflammatory perivascular infiltrates.

FIG. 4 shows the perivascular infiltrates of iPAH lung sections.

FIG. 5 shows HMHA1 in perivascular infiltrates in SSC-APAH lung samples.

DETAILED DESCRIPTION

Pulmonary hypertension (PH), or pulmonary arterial hypertension (PAH), is a chronic disease that affects the arteries in the lungs and the right side of the heart. If left untreated, PAH can lead to heart failure; thus, PAH is a disorder associated with high morbidity and mortality. The World Health Organization (WHO) classifies PH into five groups based on the underlying associated disease: Group 1: PAH, Group 2: PH due to left heart disease, Group 3: PH due to lung disease or hypoxia, Group 4: chronic thromboembolic PH (CTEPH), and Group 5: PH resulting from unclear multifactorial mechanisms.

Subjects with PAH include those with idiopathic (iPAH) or heritable PAH associated with genetic mutations in the bone morphogenic type 2 receptor (BMPR2), activin-like kinase type 1 (ALK-1), endoglin (ENG), SMAD family member 9 (SMAD9), caveolin 1 (CAV1), or potassium two pore domain channel subfamily K member 3 (KCNK3). PAH can also be associated with connective tissue disease (e.g., systemic sclerosis (scleroderma), mixed connective tissue disease, or other autoimmune disorders), human immunodeficiency virus (HIV) infection, portal hypertension, congenital heart diseases, schistosomiasis, pulmonary veno-occlusive disease, pulmonary capillary hemangiomatosis, or persistent pulmonary hypertension of the newborn (PPHN). Response to therapy is variable for subjects with PAH.

The pathology of PAH includes complex vascular formations resulting from the remodeling of pulmonary arteries called plexiform lesions (PLs) and abnormal neointimal cellular proliferation, which obstruct blood flow through the pulmonary arterioles. Kinases play a critical role in cell growth and proliferation and can be targeted to address the underlying pathology of PAH. Kinase inhibitors can be used to treat PAH upon detecting the phosphorylation of proteins involved in the pathology of PAH.

Biomarkers that indicate the pathologic mechanism, severity of the disease, and treatment response can identify subjects who require more aggressive therapeutic interventions or alternative treatments. Biomarkers can also be used to identify subjects who are more likely to respond to kinase inhibitors for the treatment of PAH.

Biomarkers for the Detection and Treatment of Pulmonary Arterial Hypertension

The disclosed invention describes a method of determining the status of diagnoses and prognoses of PAH in subjects by quantifying increases or decreases in the phosphorylation (i.e., phosphorylation profile”) of a subset of proteins. The invention describes a method of determining the phosphorylation level of one or more proteins using tissue samples of subjects with PAH. In some embodiments, the invention determines the phosphorylation level of one or more proteins using tissue samples of subjects with idiopathic PAH (iPAH). The disclosed invention compares the phosphorylation level of proteins in a sample to the phosphorylation level of the corresponding proteins in at least one control. In some embodiments, the control is a sample obtained from a subject diagnosed with PAH. In some embodiments, the control is a sample obtained from a subject diagnosed with iPAH. In some embodiments, the control is a sample obtained from a subject free of pathology.

The disclosed invention can use analytical methods to determine the relative abundance of phosphorylated proteins in PAH subjects. An increase or decrease in phosphorylation of proteins (i.e., phosphoproteins) compared to the phosphorylation levels of control samples can suggest a disease state.

The disclosed invention can identify PAH by detecting an increase in phosphorylation of at least one protein of TABLE 2. For example, the method can detect increased phosphorylation of at least one of: Ikaros family zinc finger protein 3 (IKZF3), histocompatibility (minor) antigen HA-1 (HMHA1), breast carcinoma amplified sequence 3 (BCAS3), rho-GTPase-activating protein 25 (RHG25), nuclear mitotic apparatus protein 1 (NUMA1), leukosialin (LEUK), mucin 1-cell surface associated protein (MUC1), nuclear pore complex protein Nup214 (NU214), WD repeat-containing protein 24 (WDR24), aquarius intron-binding spliceosomal factor (AQR), 1A69, apoptosis-stimulating protein of p53 1 (ASPP1), mitogen-activated protein kinase (MK14), zinc finger protein 404 (ZN404), oxysterol-binding protein (OSB11), and hepatoma-derived growth factor (HDGF). In some embodiments, the method can detect increased phosphorylation of IKZF3, HMHA1, BCAS3, RHG25, NUMA1, ZN404, and HDGF.

IKZF3 functions as an epigenetic driver of lymphocyte mimicry in metastatic epithelial cancers and plays a key role in B cell malignancies, including multiple myeloma (MM). Ikaros family zinc finger protein 1 (IKZF1) and IKZF3 are transcription factors that are essential for MM growth. Thalidomide and other drugs used for the treatment of MM bind to cereblon, a component of a ubiquitin ligase complex, and alter the specificity of the complex to induce the ubiquitination and degradation of IKZF1 and IKZF3. The phenotype of IKZF3 knockout mice is similar to that of systemic lupus erythematosus (SLE), which can cause PH.

RHG25 is a GTPase activator for Rho-type GTPases, and acts by converting Rho-type GTPases into inactive GDP-bound states. Rho-GTPases affect actin organization, cell shape, and cell spreading, and thus regulate the cytoskeleton and maintain endothelial barrier function. Cytoskeletal defects are common in the presence of multiple BMPR2 mutations and are associated with activation of the Rho-GTPase RAC1. Differences in Rho-GTPase gene expression can be observed in cultured lymphocytes between samples obtained from vasodilator reactive and non-vasodilator reactive PAH subjects.

HMHA1 is a GTPase activator for Rho-type GTPases. HMHA1 co-localizes with the Rho-GTPase Rac1. HMHA1 is expressed in hematopoietic, epithelial tumor, and endothelial cells.

NUMA1 is a component of the nuclear matrix and serves a non-mitotic structural role. NUMA1 interacts with microtubules and plays a role in the formation and organization of the mitotic spindle during cell division. NUMA1 also functions as a tether that links bulk microtubules of the spindle to centrosomes, and is required for proper alignment of the mitotic spindle during asymmetric cell divisions.

ASPP1 binds p53 and stimulates apoptotic effects. ASPP plays a role in stabilizing hematopoietic stem cells and is necessary for lymphatic vessel formation. ASPP1 also induces apoptosis independently of p53. By binding to p63 and p73 in vitro and in vivo, ASPP1 stimulates the transactivation function of p63 and p73 on the promoters of Bax, PIG3, and PUMA, but not MDM2 or p21^(WAF-I/CIP1).

HDGF is a DNA-binding nuclear factor that can cause abnormal cell proliferation, increase the expression of vascular endothelial growth factor (VEGF), and lead to angiogenesis. Dephosphorylation of HDGF can lead to endothelial cell apoptosis. HDGF can also activate the PI3K/AKT pathway.

In one embodiment, the sample phosphorylation profile of a sample comprises the phosphorylation level of IKZF3. In some embodiments, the sample phosphorylation profile of a sample comprises the phosphorylation level of IKZF3, wherein IKZF3 is phosphorylated at amino acid S378. In some embodiments, phosphorylation of IKZF3 is upregulated in PAH samples.

In one embodiment, the sample phosphorylation profile comprises the phosphorylation level of RHG25. In some embodiments, the sample phosphorylation profile comprises the phosphorylation level of RHG25, wherein RHG25 is phosphorylated at amino acid T442. In one embodiment, the sample phosphorylation profile comprises the phosphorylation level of HMHA1. In some embodiments, the sample phosphorylation profile comprises the phosphorylation level of HMHA1, wherein HMHA1 is phosphorylated at amino acid S73.

In some embodiments, the sample phosphorylation profile comprises the phosphorylation level of NUMA1, wherein NUMA1 is phosphorylated at amino acids S2047 or S1969. In some embodiments, the sample phosphorylation profile comprises the phosphorylation level of NUMA1, wherein NUMA1 is phosphorylated at amino acids S2047 and S1969. In one embodiment, the sample phosphorylation profile comprises the phosphorylation level of ASPP1. In some embodiments, the sample phosphorylation profile comprises the phosphorylation level of ASPP1, wherein ASPP1 is phosphorylated at amino acid S710.

In one embodiment, the sample phosphorylation profile comprises the phosphorylation level of HDGF. In some embodiments, the sample phosphorylation profile comprises the phosphorylation level of HDGF, wherein HDGF is phosphorylated at amino acid S107.

In one embodiment, the sample phosphorylation profile comprises the phosphorylation level of NCOR1. In some embodiments, the sample phosphorylation profile comprises the phosphorylation level of NCOR1, wherein NCOR1 is phosphorylated at amino acid 5999. In one embodiment, the sample phosphorylation profile comprises the phosphorylation level of BCAS3. In some embodiments, the sample phosphorylation profile comprises the phosphorylation level of BCAS3, wherein BCAS3 is phosphorylated at amino acid 5709.

In some embodiments, the disclosed invention can diagnose PAH by detecting a decrease in phosphorylation. In some embodiments, the method can detect decreased phosphorylation of at least one of the proteins of TABLE 3: protein tyrosine phosphatase receptor type B (PTPRB), putative synaptogyrin-2 like protein (SNGL2), HIV Tat-specific factor 1 (HTSF1), PC3 and SFRS1-interacting protein (PSIP), Annexin A2 (ANXA2), S10A9, RLA2, TM100, serine/arginine-rich splicing factor 2 (SRSF2), phospholipase D1 (PLD1), brain-specific angiogenesis inhibitor 1-associated protein 2-like protein 2 (BI2L2), TENS1, microtubule associated protein 1B (MAP1B), or catenin alpha-1 (CTNA1).

PTPRB plays an important role in blood vessel remodeling and angiogenesis. PTPRB is not necessary for the initial formation of blood vessels, but is essential for maintaining and remodeling blood vessels. In pulmonary arteries, hypoxia of smooth muscle cells (SMCs) decreases expression of several PTPs, including T cell protein tyrosine phosphatase (PTP), density-enhanced phosphatase-1, PTP1B, and SH2 domain-containing phosphatase-2, which reduce PTP activity. Hypoxia-inducible factor (HIF)-1-alpha is involved in regulating gene expression because HIF-1-alpha siRNA abolished hypoxia-induced PDGFRbeta hyperphosphorylation and PTP downregulation. PDGFRbeta hyperphosphorylation and PTP downregulation are also present in vivo in mice with chronic hypoxia-induced PH.

Histone deacetylases (HDACs) are implicated in proliferation and adventitial fibroblasts in PAH. Phosphorylation of HDAC2 is mediated by casein kinase 2 (CK2alpha). Serine phosphorylation of HDAC2 is required for subsequent acetylation of HDAC2, and serine phosphorylation of HDAC2 decreases the deacetylase activity of HDAC2. Serine phosphorylation increases interactions with transcription co-repressors, such as SAP30, RBAp46/48, MDB3, and HDAC1, as well as interactions with p65 and p53.

In some embodiments, increased phosphorylation is detected, for example, in at least 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 proteins in TABLE 2. In some embodiments, decreased phosphorylation is detected, for example, in at least 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 proteins in TABLE 3.

In some embodiments, administration of an agent increases phosphorylation in at least 1, 2, 5, or 10 proteins in TABLE 2. In some embodiments, administration of an agent increases phosphorylation in at least 1 protein in TABLE 2. In some embodiments, administration of an agent increases the phosphorylation in at least 5 proteins in TABLE 2.

In some embodiments, administration of an agent decreases phosphorylation in at least 1, 2, 5, or 10 proteins in TABLE 3. In some embodiments, administration of an agent decreases phosphorylation in at least 1 protein in TABLE 3. In some embodiments, administration of an agent decreases phosphorylation in at least 5 proteins in TABLE 3.

In some embodiments, the agent is an inhibitor of CK2, CDK1, MAPK, PRK, AKT1, AurkA, CamK2B, CAMK4, GSK3A, GSK3B, HIPK2, HYRC, PDK, DYRK2, or PAK. In some embodiments, the agent is an inhibitor of CK2. In some embodiments, the agent is an inhibitor of CDK1. In some embodiments, the agent is TBB (4,5,6,7-tetrabromo-1-H-benzotriazole).

In some embodiments, the administration of an agent inhibits phosphorylation of NUMA1 at 52047. In some embodiments, administration of an agent inhibits phosphorylation of NUMA1 at 51969. In some embodiments, the agent inhibits phosphorylation of NCOR1 at 5999. In some embodiments, administration of an agent inhibits phosphorylation of HDGF at 5107. In some embodiments, an agent decreases or inhibits the phosphorylation of HMHA1 at S73. In some embodiments, an agent decreases or inhibits phosphorylation of ASPP1 at 5710.

In some embodiments, the agent is a compound of the formula:

or a pharmaceutically-acceptable salt thereof. A pharmaceutically-acceptable salt can arise from the addition of an acid to a compound of the invention. In some embodiments, the acid is organic. In some embodiments, the acid is inorganic. In some embodiments, the acid is hydrochloric acid, hydrobromic acid, hydroiodic acid, nitric acid, nitrous acid, sulfuric acid, sulfurous acid, a phosphoric acid, isonicotinic acid, lactic acid, salicylic acid, tartaric acid, ascorbic acid, gentisinic acid, gluconic acid, glucaronic acid, saccaric acid, formic acid, benzoic acid, glutamic acid, pantothenic acid, acetic acid, propionic acid, butyric acid, fumaric acid, succinic acid, methanesulfonic acid, ethanesulfonic acid, benzenesulfonic acid, p-toluenesulfonic acid, citric acid, oxalic acid, or maleic acid. In some embodiments, the salt is a hydrochloride salt, a hydrobromide salt, a hydroiodide salt, a nitrate salt, a nitrite salt, a sulfate salt, a sulfite salt, a phosphate salt, isonicotinate salt, a lactate salt, a salicylate salt, a tartrate salt, an ascorbate salt, a gentisinate salt, a gluconate salt, a glucaronate salt, a saccarate salt, a formate salt, a benzoate salt, a glutamate salt, a pantothenate salt, an acetate salt, a propionate salt, a butyrate salt, a fumarate salt, a succinate salt, a methanesulfonate (mesylate) salt, an ethanesulfonate salt, a benzenesulfonate salt, a p-toluenesulfonate salt, a citrate salt, an oxalate salt, or a maleate salt.

Samples Used to Determine Phosphorylation Levels of Proteins

The disclosed invention can quantify changes in phosphopeptides by obtaining a sample from a human subject. In some embodiments, the sample to be tested can be lung tissue, blood, whole blood, plasma, serum, circulating cells, peripheral blood mononuclear cells (PMBCs), or a lung biopsy. In some embodiments, samples can be obtained from circulating cells, such as cells in the buffy coat isolated in a Ficoll gradient, lymphocytes or subtypes of lymphocytes (i.e., T cells, B cells, or other subtypes of T and B cells), or circulating progenitor cells (i.e., progenitor endothelial cells, fibroblasts, or stem cells). Buffy coat samples include white blood cells (leukocytes), platelets, PMBCs, lymphocytes (T cells, B cells, and NK cells), and monocytes. In some embodiments, samples can be cells isolated from a subject and grown in cell culture or transformed or immortalized. In some embodiments, samples can be cells grown using conventional cell culture methods.

Samples can be placed in a phosphatase inhibitor cocktail containing various phosphatase inhibitors and protease inhibitors to prevent dephosphorylation during sample processing. Proteins can be extracted using homogenization, sonication in radioimmunoprecipitation assay (RIPA) lysis buffer, or sonication in denaturing buffers containing detergents and inhibitors to preserve the phosphorylation state of the proteins.

Extracted, isolated proteins can be digested using proteolytic enzymes. In some embodiments, proteins are digested using LysC or trypsin. In some embodiments, proteins are digested using proteolytic enzymes and purified by column chromatography. In some embodiments, proteins are digested using proteolytic enzymes and purified using Sep-PAK cartridges or using high performance liquid chromatography (HPLC). In some embodiments, proteins are extracted using organic solvents, for example, methylene chloride, chloroform, ethyl acetate, or acetonitrile.

Isotopically-Enriched Peptides for Use as Internal Standards

In some embodiments, the amount of phosphoproteins in a sample can be compared to an amount of stable, isotopically-enriched internal standards of phosphopeptides that are upregulated or downregulated in PAH. A set of stable, isotopically-enriched peptides can be used, for example, in a parallel reaction monitoring (PRM) mass spectroscopy (PRM-MS) assay to quantify the level of target phosphoproteins.

The digested test samples can be spiked with an amount of an isotopically-enriched standard to quantify amounts of phosphopeptides. The invention can quantify the amount of wild type phosphopeptide by comparing the amount of wild type phosphopeptide in a sample to the amount of an internal standard. In some embodiments, the internal standard is an isotopically-enriched peptide of a non-phosphorylated wild type peptide. In some embodiments, the internal standard is an isotopically-enriched peptide of a phosphorylated wild type peptide.

The peptides of the invention that are used as internal standards can be enriched with stable isotopes. In some embodiments, the peptides of the invention can be labeled with ¹³C, ¹⁵N, ¹⁸O, ³²P, or any combination thereof. In some embodiments, the peptides of the invention are labeled with ¹³C. In some embodiments, the peptides of the invention are labeled with ¹⁵N. In some embodiments, the peptides of the invention are labeled with ¹³C and ¹⁵N.

Stable, isotopically-enriched peptides of the invention include stable, isotopically-enriched peptides of TABLE 2 or TABLE 3. In some embodiments, the stable, isotopically-enriched peptides of the invention are peptides of TABLE 6 and TABLE 7. The stable, isotopically-enriched peptides of the invention can be phosphorylated or non-phosphorylated. In some embodiments, the stable, isotopically-enriched peptides of the invention have 1, 2, 3, 4, or 5 phosphorylated amino acids. In some embodiments, the stable, isotopically-enriched peptides of the invention have 1 phosphorylated amino acid. In some embodiments, the stable, isotopically-enriched peptides of the invention have 2 phosphorylated amino acids.

The peptides of the invention can comprise isotopically-enriched residues of alanine, arginine, asparagine, aspartic acid, cysteine, glutamine, glutamic acid, glycine, histidine, isoleucine, leucine, lysine, methionine, phenylalanine, proline, serine, threonine, tryptophan, tyrosine, or valine. In some embodiments, the peptides of the invention comprise isotopically-enriched lysine. In some embodiments, the peptides of the invention comprise isotopically-enriched arginine. In some embodiments, the peptides of the invention comprise isotopically-enriched lysine and arginine.

The isotopically-enriched peptides of the invention can have 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, or 20 stable isotopes. In some embodiments, the isotopically-enriched peptides of the invention have 6 stable isotopes. In some embodiments, the isotopically-enriched peptides of the invention have 8 stable isotopes. In some embodiments, the isotopically-enriched peptides of the invention have 10 stable isotopes. In some embodiments, the isotopically-enriched peptides of the invention have at least 2 ¹³C nuclei. In some embodiments, the isotopically-enriched peptides of the invention have at least 5 ¹³C nuclei. In some embodiments, the isotopically-enriched peptides of the invention have at least 2 ¹⁵N nuclei.

The peptides of the invention can comprise 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 isotopically-enriched amino acid residues. In some embodiments, the peptides of the invention can comprise 1 isotopically-enriched amino acid residue. In some embodiments, the peptides of the invention can comprise 2 isotopically-enriched amino acid residues.

The isotopically-enriched peptides of the invention can share a degree of homology with the wild type peptides. A pair of wild type and isotopically-enriched peptides can have, for example, up to about 20% pairwise homology, up to about 25% pairwise homology, up to about 30% pairwise homology, up to about 35% pairwise homology, up to about 40% pairwise homology, up to about 45% pairwise homology, up to about 50% pairwise homology, up to about 55% pairwise homology, up to about 60% pairwise homology, up to about 65% pairwise homology, up to about 70% pairwise homology, up to about 75% pairwise homology, up to about 80% pairwise homology, up to about 85% pairwise homology, up to about 90% pairwise homology, up to about 95% pairwise homology, up to about 96% pairwise homology, up to about 97% pairwise homology, up to about 98% pairwise homology, up to about 99% pairwise homology, up to about 99.5% pairwise homology, or up to about 99.9% pairwise homology.

A pair of wild type and isotopically-enriched peptides can have, for example, at least about 20% pairwise homology, at least about 25% pairwise homology, at least about 30% pairwise homology, at least about 35% pairwise homology, at least about 40% pairwise homology, at least about 45% pairwise homology, at least about 50% pairwise homology, at least about 55% pairwise homology, at least about 60% pairwise homology, at least about 65% pairwise homology, at least about 70% pairwise homology, at least about 75% pairwise homology, at least about 80% pairwise homology, at least about 85% pairwise homology, at least about 90% pairwise homology, at least about 95% pairwise homology, at least about 96% pairwise homology, at least about 97% pairwise homology, at least about 98% pairwise homology, at least about 99% pairwise homology, at least about 99.5% pairwise homology, at least about 99.9% pairwise homology.

Various methods and software programs can be used to determine the homology between two or more peptides, such as NCBI BLAST, Clustal W, MAFFT, Clustal Omega, AlignMe, Praline, or another suitable method or algorithm.

Analytical Methods to Determine Phosphorylation Levels of Proteins

The disclosed invention can quantify phosphorylation levels of proteins of a test sample using various analytical methods. Phosphorylation levels of proteins of a test sample can be detected using MS, for example, PRM-MS. In some embodiments, the mass spectrometer is tuned to detect that the native protein has a different m/z ratio compared to the isotopically-enriched peptides of the invention.

Phosphorylation levels of proteins of a test sample can also be determined using HPLC/MS/MS methods, phospho-specific antibodies, western blotting or enzyme-linked immunosorbent assays (ELISAs) that use antibodies specific to phosphorylated peptides or regions of a protein, chemiluminescence, colorimetric detection methods, or horseradish peroxidase (HRP). Phosphorylation levels of proteins of a test sample can be determined by arranging proteins in arrays and analyzing the samples using flow cytometry or by plating proteins on slides for detection.

Kits for Detecting Pulmonary Hypertension

The disclosed invention also describes a kit comprising a chemical aliquot comprising a sample of an isotopically-enriched phosphopeptide that can be used to quantify phosphorylation levels of proteins in a test sample. The chemical aliquots can contain isotopically-enriched internal standards of a set of phosphopeptides. In some embodiments, a set of stable, isotopically-enriched peptides can be used to quantify amounts of phosphopeptides by PRM-MS. In some embodiments, the kit comprises unlabeled wild type peptides that are used to generate MS calibration curves.

In some embodiments, the kit comprises unlabeled, wild type peptides that can be used to generate MS calibration curves. In some embodiments, the kit can contain 4 variations of a peptide A: wild type phosphopeptide A, wild type non-phosphorylated peptide A, isotopically-enriched phosphopeptide A, and isotopically-enriched non-phosphorylated peptide A. In some embodiments, the kit consists of 4 variations of three peptides (e.g., peptides B, C, and D): 1) wild type phosphopeptide B, wild type non-phosphorylated peptide B, isotopically-enriched phosphopeptide B, and isotopically-enriched non-phosphorylated peptide B; 2) wild type phosphopeptide C, wild type non-phosphorylated peptide C, isotopically-enriched phosphopeptide C, and isotopically-enriched non-phosphorylated peptide C; and 3) wild type phosphopeptide D, wild type non-phosphorylated peptide D, isotopically-enriched phosphopeptide D, and isotopically-enriched non-phosphorylated peptide D.

The kit of the invention can comprise a chemical aliquot of a wild type or isotopically-enriched peptide that is about 0.001 to about 999 pg/mL, ng/mL, ug/mL, or mg/mL. In some embodiments, the kit of the invention can comprise a chemical aliquot of a wild type or isotopically-enriched peptide that is about 0.001, about 0.005, about 0.01, about 0.05, about 0.1, about 0.5, about 1, about 2.5, about 10, about 15, about 20, about 25, about 30, about 35, about 40, about 45, about 50, about 55, about 60, about 65, about 70, about 75, about 80, about 85, about 90, about 95, or about 100 pg/mL, ng/mL, ug/mL, or mg/mL. In some embodiments, the kit of the invention can comprise a chemical aliquot of a wild type or isotopically-enriched peptide that is about 100, about 125, about 150, about 175, about 200, about 225, about 250, about 275, about 300, about 325, about 350, about 375, about 400, about 425, about 450, about 475, about 500, about 525, about 550, about 575, about 600, about 625, about 650, about 675, about 700, about 725, about 750, about 775, about 800, about 825, about 850, about 875, about 900, about 925, about 950, or about 975 pg/mL, ng/mL, ug/mL, or mg/mL. In some embodiments, the chemical aliquot of wild type of isotopically-enriched peptides can be in femtomoles/μL (fmol/μL) or picomoles/μL (pmol/mL). In some embodiments, the invention can comprise a chemical aliquot of a wild type or isotopically-enriched peptide that is about 0.001-1000 fmol/μL or 1-1000 pmol/μL of plasma or a biological matrix.

The kit of the invention can comprise a sample of a phosphopeptide, wherein at least 0.01%, 0.1%, 0.5%, 1%, 2%, 3%, 4%, 5%, 6%, 7%, 8%, 9%, 10%, 11%, 12%, 13%, 14%, or 15% of the sample consists of molecules that have an amino acid residue that is isotopically-enriched.

The kit of the invention can be used to quantify the amount of phosphorylated peptides and corresponding phosphorylated proteins in buffy coat extracts from subjects with PAH by comparing test samples to control samples. In some embodiments, the kit can be used in an assay to compare the levels of phosphopeptides and corresponding phosphorylated proteins in subjects with PAH at specific time points compared to levels at different time points. In some embodiments, the peptide sequences are labeled with stable isotopes, such as ¹⁵N or ¹³C, which are incorporated in the C-terminal arginine or lysine of a sequence.

The disclosed kit can include stable, isotopically-enriched peptides that have terminally- or internally-labeled peptides. In some embodiments, isotopically-enriched L-lysine (H2*N(*CH2)4*CH(*NH2)*COOH.2HCl) is incorporated into phosphorylated or non-phosphorylated peptides. In some embodiments, isotopically-enriched L-arginine (H2*N*C(═*NH)*NH(*CH2)3*CH(*NH2)*COOH.HCl) is incorporated into phosphorylated or non-phosphorylated peptides.

In some embodiments, the disclosed kit comprises at least one stable, isotopically-enriched internal standard. In some embodiments, the peptides of the kit can be used in an internal standard-triggered PRM-MS assay. In some embodiments, the kit comprises 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 stable, isotopically-enriched internal standards of TABLE 6 or TABLE 7. In some embodiments, the kit comprises, 1, 2, 3, 4, or 5 isotopically-enriched internal standards of TABLE 6 or TABLE 7. In some embodiments, the kit comprises 3 isotopically-enriched internal standards of TABLE 6 or TABLE 7.

In some embodiments, the kit is used to detect increased phosphorylation in 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 proteins. In some embodiments, the kit is used to detect increased phosphorylation in 1, 2, 3, 4, or 5 proteins. In some embodiments, the kit is used to detect increased phosphorylation in at least 3 proteins. In some embodiments, the kit is used to detect decreased phosphorylation in 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 proteins. In some embodiments, the kit is used to detect decreased phosphorylation in 1, 2, 3, 4, or 5 proteins. In some embodiments, the kit is used to detect decreased phosphorylation in at least 3 proteins.

In some embodiments, the kit is used to detect increased phosphorylation in 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 proteins and to detect decreased phosphorylation in 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 proteins. In some embodiments, the kit is used to detect increased phosphorylation in 1, 2, 3, 4, or 5 proteins and to detect decreased phosphorylation in 1, 2, 3, 4, or 5 proteins. In some embodiments, the kit is used to detect increased phosphorylation in 3 proteins and to detect decreased phosphorylation in 3 proteins.

Applications of the Invention

Proteins that are identified as having increased or decreased phosphorylation can be used as biomarkers for the diagnosis of PAH in a subject. In some embodiments, the phosphoprotein levels of a test sample can be compared to phosphoprotein levels of a non-PAH control sample to detect the presence of PAH. In some embodiments, the phosphoprotein levels of a test sample can be used to determine the progression of PAH by comparing the amount of phosphoproteins to amounts of phosphoproteins from a sample obtained at an earlier time. In some embodiments, phosphoprotein levels can be monitored and compared to phosphoprotein levels of samples obtained at earlier times to monitor the effects PAH therapy.

The disclosed invention can use a scoring system to determine the presence of PAH or to monitor the progression of PAH. In some embodiments, the difference in phosphoprotein levels of a test sample and a control sample is assigned a score. Phosphoprotein levels of more than one protein can be quantified in a test sample and to generate a total score. The score or total score of a sample can be compared to a score or total score of a control sample to diagnose or monitor the progression of PAH. In some embodiments, a score or total score of a sample that is higher than a score or total score of a control sample indicates the worsening of PAH. In some embodiments, a score or total score of a sample that is lower than a score or a total score of a control samples indicates the amelioration of PAH.

The disclosed invention can be used as a companion diagnostic for PAH treatment. The invention can also be used to detect or treat PAH due to left heart disease, including PH resulting from left ventricular systolic dysfunction, left ventricular diastolic dysfunction, valvular disease, congenital or acquired left heart inflow/outflow tract obstruction, and congenital cardiomyopathies.

The invention can detect or monitor PH treatment resulting from lung disease and/or hypoxia, including chronic obstructive pulmonary disease (COPD), interstitial lung disease, other pulmonary diseases with mixed restrictive and obstructive patterns, sleep-disordered breathing, alveolar hypoventilation disorders, chronic exposure to high altitude, and developmental lung diseases.

The invention can detect or monitor PH treatment resulting from chronic thromboembolic pulmonary hypertension (CTEPH). The invention can also detect or monitor PAH treatment resulting from unclear multifactorial mechanisms, including PAH resulting from hematologic disorders (e.g., chronic hemolytic anemia, myeloproliferative disorders, spienectomy), systemic disorders (e.g., sarcoidosis, pulmonary histiocytosis, lymphangioleiomyomatosis), metabolic disorders (e.g., glycogen storage disease, Gaucher disease, thyroid disorders), and other disorders, such as tumoral obstruction, fibrosing mediastinitis, chronic renal failure, and segmental PH.

The invention can be used to identify subjects with PAH, for example, PAH associated with dysregulated immune system activation. The invention can be used to identify subjects with heritable PAH associated with genetic mutations in the bone morphogenic type 2 receptor (BMPR2), activin-like kinase type 1 (ALK-1), endoglin (ENG), SMAD family member 9 (SMAD9), caveolin 1 (CAV1), or potassium two pore domain channel subfamily K member 3 (KCNK3). The invention can be used to identify subjects with PAH associated with connective tissue disease, HIV infection, portal hypertension, congenital heart diseases, schistosomiasis, pulmonary veno-occlusive disease, pulmonary capillary hemangiomatosis, or PPHN.

The invention can be used to detect changes in the levels of phosphoproteins. In some embodiments, the invention can detect changes in the levels of phosphoproteins and determine whether these changes correlate with clinically-important endpoints, such as mortality risk, hospitalization for PAH, and listing for lung transplant. Subsets of increased and/or decreased phosphoproteins in PMBCs can be used to identify subsets of subjects with poor prognoses who are less likely to respond to therapy.

EXAMPLES I. Phosphoproteomic Analysis Example 1: Obtaining iPAH and Control Tissue Samples

Samples from subjects with iPAH were obtained at the time of lung transplantation. Control samples were obtained from donor lungs that were free of pathology and not used for transplant.

TABLE 1 shows clinical characteristics of the iPAH and control subjects. The clinical data of TABLE 1 includes the diagnosis, age, and gender of each subject. The right heart catheterization (RHC) data includes a subject's right arterial (RA) pressure in mm Hg, mean pulmonary artery (PA) pressure in mm Hg, pulmonary capillary wedge pressure (PCWP) in mm Hg, and cardiac output (CO) in L/min. TABLE 1 also shows the medications that the subjects were receiving at the time the tissue samples were obtained, which include phosphodiesterase 5 (PDE-V) inhibitors, endothelin receptor (ET) antagonists, and prostanoids.

TABLE 1 Medications RHC Data Endothelin Clinical Data RA Mean PA PCWP CO PDE-V Receptor Subject Diagnosis Age Gender mmHg mmHg mmHg L/min Inhibitor Antagonist Prostanoid 1 iPAH 40 F 7 47 7 6.17 Ambrisentan IV epoprostenol 2 iPAH 41 F 30 55 7 3.86 Sildenafil Bosentan IV epoprostenol 3 iPAH 38 F NA 50 8 2.87 Sildenafil Bosentan IV treprostinil 4 iPAH 25 M NA 59 7 4.09 Sildenafil IV epoprostenol/SC treprostinil 5 iPAH 40 M NA 64 12 3.1 Sildenafil Ambrisentan SC treprostinil 6 iPAH 51 M NA 50 8 4.6 Sildenafil IV epoprostenol 7 APAH 54 F 10 55 10 5.47 Sildenafil Ambrisentan IV epoprostenol SSC 8 APAH 65 F 6 32 6 4.35 Sildenafil Bosentan Inhaled treprostinil SSC 9 APAH 55 F 11 51 11 5.9 Sildenafil Bosentan IV epoprostenol SSC 10 Control 56 F 11 Control 49 F 12 Control 55 F 13 Control 47 M 14 Control 52 M 15 Control 17 M Abbreviations: iPAH = idiopathic PAH, APAH SSC = PAH associated with systemic sclerosis or scleroderma; RA = right atrial pressure, PA = Pulmonary artery pressure; PCWP = pulmonary capillary wedge pressure; CO = cardiac output; PDE-V = phosphodiesterase type V

Example 2: Sample Preparation for Phosphoproteomic Analysis

Lung tissue obtained from subjects with iPAH was compared to lung tissue obtained from healthy subjects using phosphoproteomic analyses. Phosphoproteomic analyses were performed using frozen lung tissue from three iPAH female subjects, three male iPAH subjects, three healthy female subjects (female control), and three healthy male subjects (male controls).

The lung tissue samples of each sample group were homogenized in RIPA buffer (158 mM NaCl, 10 mM TRIS pH 7.2, 0.1% SDS, 1% Triton×100, 1% deoxycholate, 1 mM EGTA, 40 mM beta-glycerophosphate, 30 mM sodium fluoride, 10 mM sodium pyrophosphate, 1 mM imidazole, 2 mM sodium orthovanadate, 1 Roche minitab protease inhibitor, 1 Roche minitab phosphostop tab/10 mL) using a Powergen™ homogenizer (VWR). The samples were spun by centrifuge at 10,000 rotations per minute (rpm), and the supernatant was sonicated and spun again.

The protein concentrations of the samples were determined using bicinchoninic acid (BCA) assays. The samples were stored at −80° C. until use. The proteins were precipitated with chloroform and methanol, resuspended in an 8 M urea/0.4M ammonium bicarbonate solution, and subjected to Lys C/trypsin digestion.

Whole lung homogenates for each group were pooled, enriched for phosphoproteins using strong cation exchange chromatography and repetitive TiO₂-based column chromatography (SCX/TiO₂), and subjected to LCMS/MS analyses.

Example 3: Phosphoproteomic Analyses of Tissue from Subjects with iPAH

A quantitative label-free phosphorproteomics strategy was used to identify peptides and to determine relative differences in phosphopeptides of the iPAH and control tissue samples.

Instrumentation:

An LTQ Orbitrap ELITE™ (Thermo Scientific™) equipped with a Waters nanoAcquity™ ultra performance liquid chromatography (UPLC™) system, a Waters Symmetry® C18 180 μm×20 mm trap column, and a 1.7 μm, 75 μm×250 mm nanoAcquity™ UPLC™ column (35° C.) was used for peptide separation. Trapping was done using 99% of buffer A (0.1% formic acid in water) at a flow rate of 5 μL/min for 3 min. Peptide separation was performed with a linear gradient over 200 min using Buffer B (0.1% formic acid in acetonitrile) at a flow rate of 300 nL/min.

Data Analysis:

Feature extraction, chromatographic/spectral alignment, data filtering, statistical analysis, and LFQ data were processed using Progenesis™ LC-MS software (Nonlinear Dynamics, LLC.). The ‘.raw’ data files were imported into the program, and a sample run was chosen as a reference. The reference was usually at or near the middle of all the runs in a sample set. All other runs were automatically aligned to the sample run to minimize retention time (RT) variability between runs. No adjustments were necessary in the m/z dimension due to the high mass accuracy of the spectrometer, which was typically <3 ppm. All runs were selected for detection with an automatic detection limit. The enriched and flow-through fractions were processed separately.

A normalization factor was then calculated for each run to account for differences in sample loads between injections. Multiple injections from each run were grouped together. The algorithm then calculated and tabulated raw and normalized abundances, max fold changes, and Anova values for each feature in the data set. The features were tagged in sets based on characteristics, such as MSMS >1 and p<0.05. The remaining MS/MS data were exported as a Mascot generic file (.mgf) for database searching. After the Mascot (Matrix Science) search, an .xml file of the results was created and imported into Progenesis™ LCMS software where search hits were assigned to corresponding features.

Database Searching:

The ‘.mgf’ files created by the Progenesis™ LC-MS software were searched and identified using a Mascot search algorithm for un-interpreted MS/MS spectra. Search parameters were as follows:

-   -   The database searched: Swissprotein     -   Taxonomy: human     -   Confidence level: 95% within the Mascot search engine for         protein hits based on randomness.     -   Type of search: MS/MS ion search     -   Enzyme: Trypsin/Lys C     -   Variable modifications: carbamidomethyl (Cys), oxidation (Met),         phospho (Ser, Thr, Tyr)     -   Mass values: monoisotopic     -   Protein mass: unrestricted     -   Peptide mass tolerance: ±5 ppm     -   Fragment mass tolerance: ±0.2 Da     -   Charge: +7     -   Max missed cleavages: 3     -   Decoy: yes

A confidence level of 95% meant that if 1500 peptides fell within the mass tolerance window about the precursor mass and the significance threshold was chosen to be 0.05 (95% confidence level), there would be a 1 in 20 chance of the protein identification being a false positive.

Using the Mascot database search algorithm, a protein was considered a positive hit when Mascot listed the pattern as significant and more than 2 unique peptides matched the same protein. A Mascot significance score match is based on a molecular weight search (MOWSE) score and relies on multiple matches to more than one peptide from the same protein. The Mascot search results were exported to an .xml file using a significance cutoff of p<0.05. Q values were also calculated.

The enriched phosphopeptide analysis generated 60,428 features. From these features, 6622 proteins were identified. Within the subset of identified proteins, 1480 phosphopeptides had q<0.05. The relative enrichment of phosphopeptides with q<0.05 in female iPAH vs. female controls, and male iPAH vs. male controls was determined.

TABLE 2 shows 10 phosphopeptides that had the highest phosphorylation ratios. Results show an increase in phosphorylation for IKZF3, HMHA1, BCAS3, RHG25, NUMA1, LEUK, MUC1, NU214, WDR24, AQR, 1A69, ASPP1, MK14, ZN404, OSB11, and HDGF.

IKZF3 phosphorylated at 5378 had the highest phosphorylation ratio, and no phosphorylation was detected in the control samples. A high relative abundance of phosphorylated HMHA1 at S73 was also found. HMHA1 had a 6-fold increase in phosphorylation for male iPAH samples compared to male controls. BCAS3 phosphorylated at S709 exhibited a 119-fold increase for female iPAH samples and a 10-fold increase in male samples compared to their respective controls. The amount of phosphorylated RHG25 at T442 increased 18.95-fold in iPAH female samples and 2.75-fold for iPAH male samples.

NUMA1 phosphorylated at 52047 demonstrated a 15-fold increase in female iPAH samples. In male iPAH samples, NUMA1 phosphorylated at 52047 was not detected in the control, and provided an “infinite (co” increase in phosphorylation (i.e., male control denominator was zero). NUMA1 phosphorylated at S1969 increased by 15-fold in female iPAH samples compared to the corresponding control. NCOR1 phosphorylated at 5999 showed a 7.4-fold increase in female iPAH samples compared to a 3.3-fold increase in male iPAH samples (data not shown).

The amount of phosphorylated ASPP1 at 5710 increased 8.8-fold in iPAH females compared to the female control, and increased by 208.7-fold in male iPAH lung samples compared to the control. HDGF phosphorylated at S107 exhibited an 8.1-fold increase in female iPAH samples and a 37.1-fold increase in male iPAH samples compared to the respective controls.

TABLE 2 Variable modifications Female Male SEQ ([position] iPAH/ iPAH/ ID NO. Protein Sequence description) Control control)  1 IKZF3 GLSPNNSGHDSTDTDSNHEER  [3] Phospho (S) ∞ ∞  2 HMHA1 HASAAGFPLSGAASWTLGR  [3] Phospho (S) ∞   6.4908  3 BCAS3 HGSYDSLASDHSGQEDEEWLSQVEIVT  [6] Phospho (S) 119.2601  10.7002 HTGPHR  4 RHG25 RTQTLPNRK  [4] Phospho (T)  18.9477   2.7541  5 NUMA1 RQSMAFSILNTPK  [3] Phospho (S)  15.3163 ∞  6 LEUK RPTLTTFFGR  [3] Phospho (T)  11.9439   2.2581  7 MUC1 DTYHPMSEYPTYHTHGR [11] Phospho (T)  10.636   14.2286  8 NU214 TPSIQPSLLPHAAPFAK  [3] Phospho (S)  10.3986   4.0896  9 WDR24 IIYCSPGLVPTANLNHSVGK  [4] Carbamidomethyl (C)  10.2661   3.3501 [11] Phospho (T) 10 NUMA1 RASMQPIQIAEGTGITTR  [3] Phospho (S)   9.7252  12.1185 11 AQR DFSRYGRVNYVLARR [10] Phospho (Y)   9.5689   0.4385 12 1A69 GGSYSQAASSDSAQGSDVSLTACK  [9]Phospho (S)   9.2518  24.0789 [23] Carbamidomethyl (C) 13 ASPP1 RSSITEPEGPGGPNIQK  [3] Phospho (S)   8.8137 208.7079 14 MK14 HTDDEMTGYVATR  [7] Phospho (T)   8.7404   3.1787  [9] Phospho (Y) 15 ZN404 HSHLTEHQK  [5] Phospho (T)   8.6749   3.6109 16 OSB11 RPSQNAISFFNVGHSK  [3] Phospho (S)   8.3782   4.9584 17 HDGF SCVEEPEPEPEAAEGDGDK  [1] Phospho (S)   8.091   37.1543  [2] Carbamidomethyl (C) Table nomenclature: A square bracket, i.e., [3] means the amino acid position in the sequence that is phosphorylated or carbamidomethylated; the parentheses bracket means the amino acid at that position which is phosphorylated, i.e. (S). e.g., for SEQ ID NO. 1, the serine at position 3 in the sequence is phosphorylated. The IUPAC amino acid code system is used for amino acid abbreviations.

Western blots with custom-made phospho-specific (S378) antibody were analyzed to confirm that the amount of phosphorylated S378 IKZF3 was increased in iPAH lung extract relative to controls. A rabbit polyclonal IgG antibody was made against the N-terminus of IKZF3 and a phospho-specific site of IKZF3 at the C-terminus. The antibodies were subjected to affinity purification and negative adsorption. Phospho-specific and total antibodies against IKZF3 were used in Western blots to compare phospho-protein levels in iPAH, scleroderma-associated PAH (SSC-APAH), and control samples.

FIG. 1 Panel A shows that the signal for IKZF3 phosphorylated at S378 was higher in iPAH (n=5) samples compared to control samples (n=6). FIG. 1 Panel B shows that the signal for IKZF3 phosphorylated at S378 IKZF3 was higher in SSC-APAH samples (n=3) compared to control samples (n=3).

Immunohistochemistry experiments confirmed the presence of proteins in TABLE 2 and TABLE 3, and indicated immune and inflammatory cell involvement in the pathology of PAH. A custom pIKZF3 antibody was used for immunohistochemistry experiments. T cell markers and B cell markers were used to localize expression of pIKZF3 to specific cell types in iPAH, SSC-APAH, and control lung sections. Immunohistochemistry was also performed using an anti-HMHA1 antibody.

Immunohistochemistry experiments demonstrated that pIKZF3 in perivascular infiltrates in iPAH lung samples were predominantly T cells with some B cells present, neither of which were found in normal controls. Immunohistochemistry experiments also demonstrated that pIKZF3 in lymphocytes surrounding severely hypertrophied pulmonary arterioles. FIG. 2 shows that iPAH samples (FIG. 2 Panel C and FIG. 2 Panel D) had increased pIKZF3 in perivascular infiltrates compared to control samples (FIG. 2 Panel A and FIG. 2 Panel B). Cells staining positive for phosphorylated S378 IKZF3 densely surround a hypertrophied pulmonary arteriole. The perivascular infiltrates were found to contain of a mixed population of CD3⁺, CD8⁺ T cells, and CD20⁺ B cells. CD45ra⁺ T cells were also detected but to a lesser degree.

FIG. 3 shows the immunohistochemistry of iPAH lung tissue and shows inflammatory perivascular infiltrates. CD3: antibody against a T cell marker; CD20: antibody against a B cell marker; pIKZF3: antibody against S378 pIKZF3. pIKZF3 was predominantly present in perivascular cells, but were also seen in endothelial-like cells of the diseased pulmonary arteriole. The perivascular cells were predominantly T cells with some B cells present which were not found in normal controls.

FIG. 3 Panel A shows pIKZF3 with a 10× objective. FIG. 3 Panel B shows pIKZF3 with a 40× objective. The arrow points to a small lumen of a pulmonary arteriole with staining of the endothelium. FIG. 3 Panel C shows CD3 T cell markers with a 10× objective. FIG. 3 Panel D shows CD3 T cell markers with a 40× objective. The T cells were primarily found to be perivascular, and more T cells were found than B cells. FIG. 3 Panel E shows the CD20 B cell marker with a 10× objective. FIG. 3 Panel F shows the CD20 B cell marker with a 40× objective.

FIG. 4 shows that the perivascular infiltrates seen in iPAH lung sections were highly positive for CD8 (FIG. 4 Panel A: 10× objective; FIG. 4 Panel B: 40× objective). Scattered cells in the perivascular infiltrates stained positive for CD45RA. CD45RA is a protein tyrosine phosphatase and is used as a marker for cytolytic T lymphocytes.

HMHA1 was also localized to perivascular infiltrates surrounding remodeled pulmonary arterioles. Cells surrounding a pulmonary arteriole were highly positive for HMHA1 in the SSC-APAH sample. FIG. 5 Panel A and Panel B show HMHA1 in normal controls. FIG. 5 Panel C and 5 Panel D show perivascular infiltrates in SSC-APAH lung samples (FIG. 5 Panel C: 10× objective; FIG. 5 Panel D: 40× objective). FIG. 5 Panel E and 5 Panel F show HMHA1 in perivascular infiltrates in iPAH lung samples (FIG. 5 Panel E: 10× objective; FIG. 5 Panel F: 40× objective).

TABLE 3 shows 10 phosphopeptides that had the lowest phosphorylation ratios. Phosphorylated proteins that exhibited low relative abundance compared to control samples in iPAH female and male samples included phosphorylated forms of PTPRB, SNG2L, HTSF1, PSIP1, ANXA2, 510A9, RLA2, TM100, SRSF2, PLD1, BI2L2, TENS1, MAP1B, and CTNA1.

Phosphorylation of HDAC2 at S422 was decreased in female and male iPAH lung samples compared to controls. Phosphorylation of PTPRB was completely absent at S119.

TABLE 3 Variable modifications Female Male SEQ ([position] PAH/ PAH/ ID NO. Protein Sequence description) Control control 18 PTPRB FGVSKEK  [4] Phospho (S) 0.00 0.00 19 SNG2L ALCLVFALIVFSCIYGEGYSNTHKSK  [3] Carbamidomethyl (C) 0.01 0.27 [13] Carbamidomethyl (C) [19] Phospho (Y) [20] Phospho (S) [22] Phospho (T) [25] Phospho (S) 20 HTSF1 VLDEEGSEREFDEDSDEKEEEEDTYEK [15] Phospho (S) 0.02 0.28 21 PSIP1 TGVTSTSDSEEEGDDQEGEK  [9] Phospho (S) 0.02 0.04 22 ANXA2 IMVSRSEVDMLKIR  [4] Phospho (S) 0.02 0.08 [10] Oxidation (M) 23 S10A9 MHEGDEGPGHHHKPGLGEGTP [20] Phospho (T) 0.07 0.80 24 RLA2 KEESEESDDDMGFGLFD  [7] Phospho (S) 0.08 0.04 25 TM100 RRESQTALVANQR  [4] Phospho (S) 0.12 0.43 26 SRSF2 SRSPPPVSK  [3] Phospho (S) 0.13 0.28 27 PLD1 MSLKNEPRVNTSALQK [11] Phospho (T) 0.18 0.82 [12] Phospho (S) 28 BI2L2 LMSSEQYPPQELFPR  [3] Phospho (S) 0.21 1.36 29 TENS1 AASDGQYENQSPEATSPRSPGVR  [3] Phospho (S) 0.21 0.90 [16] Phospho (S) [19] Phospho (S) 30 MAP1B RESVASGDDRAEEDMDEAIEK  [3] Phospho (S) 0.22 0.19 31 CTNA1 SRTSVQTEDDQLIAGQSAR  [4] Phospho (S) 0.24 0.29 Table nomenclature: A square bracket, i.e., [3] means the amino acid position in the sequence that is modified; the parentheses bracket means the amino acid at that position which is modified, i.e. (S). e.g., for SEQ ID NO. 18, the serine at position 4 in the sequence is phosphorylated. Abbreviations for modifications: Phospho = phosphorylation; Carbamidomethyl = carbamidomethylation. S = serine, T = Threonine, Y = tyrosine. The IUPAC amino acid code system is used for amino acid abbreviations.

II. Using Biomarkers to Detect and Diagnose PAH Example 4: Preparing Samples for Use in Biomarker Assays

PBMCs or buffy coats are lysed in RIPA buffer (158 mM NaCl, 10 mM TRIS pH 7.2, 0.1% SDS, 1% Triton×100, 1% deoxycholate, 1 mM EGTA, 40 mM beta-glycerophosphate, 30 mM sodium fluoride, 10 mM sodium pyrophosphate, 1 mM imidazole, 2 mM sodium orthovanadate, 1 Roche minitab protease inhibitor, 1 Roche minitab phosphostop tab/10 mL) and spun by centrifuge at 14,000 rpm for 10 minutes. After centrifugation, the supernatants are collected and proteins are precipitated using a methanol-chloroform mixture.

The resulting protein pellets are resuspended in 0.1 M tetraethyl ammonium bromide (TEAB)/0.1% RapiGest™ buffer, reduced with tris(2-carboxyethyl)phosphine (TCEP) for 60 minutes at 55° C., and then alkylated with iodoacetamide for 30 min at room temperature in the dark. The denatured proteins are digested with trypsin by incubating the samples overnight at 37° C. The peptide concentration of the tryptic digest is determined by amino acid analysis using a Hitachi L-8900 Amino Acid Analyzer™. The tryptic digests are enriched for phosphopeptides using a TiO₂ enrichment kit (ThermoFisher Scientific™) and desalted using Sep-Pak cartridges.

The enriched phosphopeptides are spiked with stable isotope-labeled phosphopeptide internal standards, and the mixture is subjected to PRM-MS analysis. Buffy coat samples can also be labeled with internal standards and unlabeled phosphopeptides to determine extraction efficiencies. Quality control samples at low, medium, and high concentration are included in the analyses. Precision, accuracy, linear range, lowest limit of detection (LLOD), and lowest limit of quantification (LLOQ) levels are determined for the entire phosphopeptide set.

Acceptance Criteria:

Linearity is 4 to 5 orders of magnitude and has coefficients of variability of ≦10%. LLOQ is defined as the lowest concentration where the coefficient of variation (CV) of triplicate injections is less than 20% with an average accuracy within 80-120%. Above the LLOQ, the accuracy (measured-nominal)/measured concentration is ±15%. Precision (SD of replicates)/mean of replicates is ≦15%. Sensitivity is on the order of femtomoles/ml and is similar to some enzyme-linked immunosorbent (ELISA) assays.

Mass Spectrometric Data Acquisition:

The samples are analyzed using PRM on an Orbitrap-Fusion™ Tribrid™ MS interfaced at the front end with a Waters® nanoACQUITY UPLC® System. First, a spectral library is generated by performing data-dependent acquisition (DDA) in the Orbitrap-Fusion™. For DDA, a full-scan MS spectrum (m/z range 400-1600) is acquired in the Orbitrap region with a resolution of 120,000, automatic gain control (AGC) target of 4×10⁵, and maximum injection time of 50 ms. The precursor ions for MS/MS are selected based on and starting from the most intense ion in the full-scan MS spectra. The precursor ions for MS/MS are in the quadrupole region with an isolation window of 1.6 m/z, and are fragmented by higher-collisional energy dissociation (HCD) in the ion trap region with normalized collision energies set to 28. The fragmentation spectra are acquired in the Orbitrap region with a resolution of 60,000, AGC target of 1×10⁵, and maximum injection time of 120 ms. Selection and fragmentation of ions contain a dynamic exclusion setting of 15 s to minimize repeat sequencing of peptides.

For PRM-MS, the Orbitrap-Fusion™ MS is operated in targeted-MS² data acquisition mode. Information, such as the precursor m/z, charge state, and elution time needed to build the inclusion list for the analysis of the target light and heavy peptides by PRM are obtained from the acquired DDA data. The data acquisition parameters for PRM are similar to parameters for the MS/MS scans in DDA mode. The cycle time of the MS/MS scans are kept to 3 s or less to obtain at least 10 data points across chromatographic peaks, assuming the average width of a chromatograph is ˜30 s.

To increase the number of phosphopeptides for the assay list, a scheduled PRM method can be implemented. In the scheduled PRM method, target peptides are only targeted over a preselected LC retention time, as determined in the first DDA experiment. The spectral library is used in Skyline analysis software to assign and quantify target peptides. Scheduled monitoring also ensures the highest plexing capabilities for the various peptides to be quantified. Scheduling means that test samples are run to determine the precise retention time associated with each of the target peptides.

Data Analysis:

The MS raw data from DDA analysis are processed using Proteome Discoverer™ v2.0 (Thermo Scientific) software. The files are searched against the human SwissProt database using Sequest HT and Mascot search algorithms. Peptide spectrum matches (PSMs) are verified based on q-values set to a 1% false discovery rate (FDR) using Percolator (Matrix Science). The list of proteins and peptides identified serve as the spectral library for the PRM data analysis in Skyline software. Quantification of a targeted peptide is based on the top five ranked product ions of each precursor ion selected.

The processed Skyline data is manually verified, and product ions with interferences are removed and replaced with the next highest-ranking product ions. The ratios of integrated peak areas of fragment ions of light to heavy peptides across the samples are used for relative quantification of the samples. Phosphorylation at a site of interest is normalized to the average abundance of several non-phosphorylated sites of the protein to create a relative abundance value for the degree of phosphorylation.

Example 5: Phosphatase Inhibitor Treatment of Buffy Coat Extracts

A stability study is performed to determine the effects of adding an inhibitor cocktail directly to blood samples, adding an inhibitor cocktail after isolation of the buffy coat, or washing the buffy coat cells with buffer containing an inhibitor cocktail after isolation but prior to extraction. Stability of the buffy coat extracts is determined using a PRM-MS assay and Western blot analyses for selected phosphoproteins using research grade phospho-specific antibodies. Phospho-specific antibodies for stability studies include antibodies for pIKZF3, pNUMA1, and pHDAC2.

The samples are collected in BD Vacutainer® CPT™ Cell Preparation Tubes with sodium citrate and ficoll following BD's published collection procedure (REF 362761). The collection procedure spins by centrifuge, separates, washes, and concentrates the PBMCs for further use. The collection procedure is modified by adding a phosphatase inhibitor cocktail or washing the cells with a buffer containing the inhibitor cocktail to preserve the stability of the phosphoproteins.

A phosphatase inhibitor cocktail is added to blood samples at the time of blood collection or to the buffy coat after isolation from PBMCs. A non-lysing non-denaturing inhibitor cocktail is added to blood samples. For buffy coat samples, the samples are resuspended in a lysing buffer and snap frozen in liquid nitrogen for storage prior to assaying the samples. Both non-phosphatase-inhibited and phosphatase-inhibited samples are tested to determine whether phosphatase inhibition is required and, if so, required at what stage of the collection process. Samples are considered acceptable when less than 25% degradation in signal.

Extraction of Proteins:

The cytoplasmic proteins, including the phosphoproteins, are extracted from the PBMCs following the Thermo Fisher™ (Pierce) procedure 89900 and using RIPA buffer. This procedure is compatible with or without the phosphate inhibitor cocktail. Protein extraction from the PBMCs is tested by quantifying total protein content, total phosphoprotein content, and identifying of each specific phosphoprotein resulting from the proteomic analysis described above.

Example 6: Baseline Screening of Control Samples and PAH Samples

Buffy coat cells and PBMCs are collected from subjects with PAH, SSC subjects without PAH, and healthy subjects. A Health Insurance Portability and Accountability Act (HIPAA) compliant database allows for analysis of clinical parameters. The database has restricted access, and subject identifiers are removed prior to release of clinical data matched to samples. The clinical courses of study subjects are followed over time, and changes in candidate biomarkers over time are correlated with clinical outcome.

Clinical parameters include age, gender, PH classification, genetic markers (i.e., presence of BMPR2 mutations, ALK, or endoglin mutations), medications, functional class, six-minute walk distance, cardiopulmonary hemodynamics, and clinical course (i.e., hospitalization, listing for lung transplant, mortality).

The study is performed using a test data set and a verification data set. The test set enrolls subjects with PAH (n=30 iPAH, n=30 SSC-APAH), subjects with SSC without PAH (n=20), and normal controls (n=20). The verification set uses assays (described above) that show significant differences between PAH subjects and normal controls to screen a similar cross section of subjects with PAH (n=30 iPAH, n=30 SSC APAH), subjects with SSC but without PAH (n=20), and normal controls (n=20).

The results of PRM-MS assays for designated phosphoproteins are correlated with parameters in the clinical database, listed above. Inclusion criteria include: age>18 yrs, diagnosis of PAH, SSC without PAH, or normal controls. Subjects acting as normal controls have no history of systemic illness such as hypertension, DM, thyroid disease, bleeding abnormality, active infection, asthma, cancer, renal failure, smoking, or drug abuse. Exclusion criteria include: age<18 yrs, co-morbid conditions such as current cancer, or treatment with immunosuppressants including steroids.

Analyses:

Analyses of biomarkers for the diagnosis of PAH (present/absent) and analyses of biomarkers for prognosis of PAH (good/bad) are conducted. Analyses of biomarkers for prognosis of PAH attempt to identify the set of phosphoproteins that predict worsening PAH. Worsening PAH includes an increase in mortality, increase in hospitalization for PAH, decrease in six-minute walk distance (6MWD), worsening functional class, need for lung transplantation, or need for addition of a prostanoid.

The Wilcoxon rank sum test is used to determine the association between individual phosphoprotein biomarkers and the presence of PAH or the worsening of PAH. Phosphoprotein levels are analyzed using logistic regression. Regression coefficients are combined to form “classifier scores.” Diagnostic tests are determined to be positive or negative when the linear combination is either ≧ or < than a cut-off threshold. For a given cut-off threshold, ROC curves are generated by plotting sensitivity vs 1-specificity. All biomarker subsets are examined to evaluate the predictive value of each subset.

After identifying candidate logistic regression models, the models are “tuned” using cross validation. The minmax concave penalty method (MCP) is also used for variable selection, which has larger predictive AUCs for ROC curves. Upon identifying the best model, the model is applied to a verification set. A power calculation for logistic regression is performed using XLSTAT™ (Pearson) or a similar program. Parameters for a sample size of 30 includes: alpha set at 0.05, baseline probability of 0.1, alternative probability of 0.7: beta=0.057, and power=0.943. If alternative probability is set at 0.6, then the power decreases to 0.85.

Example 7: Stable, Isotopically-Enriched Peptide Sequences

Stable, isotopically-enriched variants of the peptides in TABLE 2 and TABLE 3 are prepared and used as internal standards in PRM-MS assays to detect or monitor the progression of PAH. In some embodiments, stable, isotopically-enriched arginine (R) or lysine (K) is introduced at the C-terminus of each peptide of TABLE 2 and TABLE 3 and the corresponding non-phosphorylated peptides. In some embodiments, stable, isotopically-enriched arginine (R) or lysine (K) is embedded in the sequence of each peptide of TABLE 2 and TABLE 3 and the corresponding non-phosphorylated peptides.

TABLE 4 shows an example of isotopically-labeled L-arginine used to synthesize stable, isotopically-enriched peptides. TABLE 5 shows an example of isotopically-labeled L-lysine used to synthesize stable, isotopically-enriched peptides.

TABLE 4

Chemical formula H2*N*C(=*NH)*NH(*CH2)3*CH(*NH2)*COOH•HCl Unlabeled CAS # 1119-34-2 Labeled CAS # 202468-25-5 Molecular weight 220.59 Chemical purity 98%

TABLE 5

Chemical formula H2*N(*CH2)4*CH(*NH2)*COOH•2HCl Unlabeled CAS # 657-26-1 Labeled CAS # N/A Molecular weight 227.05 Chemical purity 98%

TABLE 6 shows stable, isotopically-labeled phosphorylated and non-phosphorylated peptides of the 17 phosphopeptides that had the highest phosphorylation ratios (TABLE 2), and can be used as standards in PRM-MS assays. The phosphorylated and non-phosphorylated peptide sequences are shown with variable modifications. The variable phosphorylated amino acids are shown in parentheses (e.g., (S) or (T)). Stable, isotopically-enriched amino acids are shown in curly brackets (e.g., {K}).

TABLE 7 shows stable, isotopically-labeled phosphorylated and non-phosphorylated peptides of 14 phosphopeptides that had the lowest phosphorylation ratios (TABLE 3), and can be used as standards in PRM-MS assays. The phosphorylated and non-phosphorylated peptide sequences are shown with variable modifications. The variable phosphorylated amino acids are shown in parentheses (e.g., (S)). Stable, isotopically-enriched amino acids are shown in curly brackets (e.g., {K}).

TABLE 6 SEQ Phosphorylated peptide SEQ Nonphosphorylated peptide Protein ID NO. for PRM assay ID NO. for PRM assay IKZF3_HUMAN 32 GL(S)PNNSGHDSTDTDSNHEE{R} 33 GLSPNNSGHDSTDTDSNHEE{R} HMHA1_HUMAN 34 HA(S)AAGFPLSGAASWTLG{R} 35 HASAAGFPLSGAASWTLG{R} BCAS3_HUMAN 36 HGSYD(S)LASDHSGQEDEEWLSQ 37 HGSYDSLASDHSGQEDEEWLSQ VEIVTHTGPH{R} VEIVTHTGPH{R} RHG25_HUMAN 38 RTQ(T)LPNR{K} 39 RTQTLPNR{K} NUMA1_HUMAN 40 RQ(S)MAFSILNTP{K} 41 RQSMAFSILNTP{K} LEUK_HUMAN 42 RPTLTTFFG{R} 43 RPTLTTFFG{R} MUC1_HUMAN 44 DTYHPMSEYP(T)YHTHG{R} 45 DTYHPMSEYPTYHTHG{R} NU214_HUMAN 46 TP(S)IQPSLLPHAAPFA{K} 47 TPSIQPSLLPHAAPFA{K} WDR24_HUMAN 48 ITYCSPGLVP(T)ANLNHSVG{K} 49 ITYCSPGLVPTANLNHSVG{K} NUMA1_HUMAN 50 RA(S)MQPIQIAEGTGITT{R} 51 RASMQPIQIAEGTGITT{R} AQR_HUMAN 52 DFSRYGRVN(Y)VLA{R} 53 DFSRYGRVNYVLA{R} 1A69_HUMAN 54 GGSYSQAA(S)SDSAQGSDVSLTAC{K} 55 GGSYSQAASSDSAQGSDVSLTAC{K} ASPP1_HUMAN 56 RS(S)ITEPEGPGGPNIQ{K} 57 RSSITEPEGPGGPNIQ{K} MK14_HUMAN 58 HTDDEM(T)G(Y)VAT{R} 59 HTDDEMTGYVAT{R} ZN404_HUMAN 60 HSHL(T)EHQ{K} 61 HSHLTEHQ{K} OSB11_HUMAN 62 RP(S)QNAISFFNVGHS{K} 63 RPSQNAISFFNVGHS{K} HDGF_HUMAN 64 (S)CVEEPEPEPEAAEGDGD{K} 65 SCVEEPEPEPEAAEGDGD{K} Parentheses (e.g., (S) or (T)) indicate phosphorylation of the amino acid Curly brackets (e.g., {K}) indicate a stable, isotopically labeled amino acid

TABLE 7 Phosphorylated Nonphosphorylated SEQ peptide from SEQ peptide for Protein ID NO. PRM assay ID NO. PRM assay PTPRB_HUMAN  66 FGV(S)KE{K}  67 FGVSKE{K}  68 PARFGV(S)KE{K}  69 PARFGVSKE{K} SNG2L_HUMAN  70 ALCLVFALIVFSCIYGEG(Y)  71 ALCLVFALIVFSCIYGEGY (S)N(T)HK(S){K} SNTHKS{K}  72 IYGEG(Y)(S)N(T)HK(S){K}  73 IYGEGYSNTHKS{K} HTSF1_HUMAN  74 VLDEEGSEREFDED(S)DEKEEEED  75 VLDEEGSEREFDEDSDEKEEEEDT TYE{K} YE{K} PSIP1_HUMAN  76 TGVTSTSD(S)EEEGDDQEGE{K}  77 TGVTSTSDSEEEGDDQEGE{K} ANXA2_HUMAN  78 IMV(S)RSEVDMLKI{R}  79 IMVSRSEVDMLKI{R}  80 V(S)RSEVDMLKI{R}  81 VSRSEVDMLKI{R} S10A9_HUMAN  82 MHEGDEGPGHHH{K}PGLGEG(T)P  83 MHEGDEGPGHHH{K}PGLGEGTP  84 HEGDEGPGHHH{K}PGLGEG(T)P  85 HEGDEGPGHHH{K}PGLGEGTP RLA2_HUMAN  86 {K}EESEE(S)DDDMGFGLFD  87 {K}EESEESDDDMGFGLFD TM100_HUMAN  88 RRE(S)QTALVANQ{R}  89 RRESQTALVANQ{R} SRSF2_HUMAN  90 SR(S)PPPVS{K}  91 SRSPPPVS{K} PLD1_HUMAN  92 MSLKNEPRVN(T)(S)ALQ{K}  93 MSLKNEPRVNTSALQ{K}  94 SLKNEPRVN(T)(S)ALQ{K}  95 SLKNEPRVNTSALQ{K} BI2L2_HUMAN  96 LM(S)SEQYPPQELFP{R}  97 LMSSEQYPPQELFP{R} TENSl_HUMAN  98 AA(S)DGQYENQSPEAT(S)PR(S)PG  99 AASDGQYENQSPEATSPRSPGV{R} V{R} MAP1B_HUMAN 100 RE(S)VASGDDRAEEDMDEAIE{K} 101 RESVASGDDRAEEDMDEAIE{K} CTNA1_HUMAN 102 SRT(S)VQTEDDQLIAGQSA{R} 103 SRTSVQTEDDQUAGQSA{R} Parentheses (e.g., (S) or (T)) indicate phosphorylation of the amino acid Curly brackets (e.g., {K}) indicate a stable, isotopically labeled amino acid

EMBODIMENTS

The following non-limiting embodiments provide illustrative examples of the invention, but do not limit the scope of the invention.

Embodiment 1

A method comprising: a) adding to a sample of a protein extracted from a buffy coat an amount of a quantification standard to provide a test sample; and b) assaying the test sample to quantify in the test sample a wild type phosphopeptide of the protein extracted from the buffy coat, wherein the quantifying is based on the amount of the quantification standard, wherein the quantification standard is a form of the phosphopeptide that is isotopically-enriched to a non-natural abundance of an isotope.

Embodiment 2

The method of embodiment 1, further comprising: a) obtaining a tissue sample from a human subject, wherein the tissue sample contains the buffy coat; and b) isolating the protein from the tissue sample to provide the sample of the protein.

Embodiment 3

The method of any one of embodiments 1-2, further comprising digesting the sample of protein prior to adding the amount of the quantification standard.

Embodiment 4

The method of any one of embodiments 2-3, wherein the human subject has pulmonary hypertension.

Embodiment 5

The method of any one of embodiments 2-4, wherein the human subject has pulmonary arterial hypertension.

Embodiment 6

The method of any one of embodiments 4-5, wherein the pulmonary hypertension is idiopathic pulmonary hypertension.

Embodiment 7

The method of any one of embodiments 4-5, wherein the pulmonary hypertension is pulmonary hypertension associated with systemic sclerosis.

Embodiment 8

The method of any one of embodiments 1-7, wherein the quantification standard is an isotopically-enriched peptide of TABLE 2 or TABLE 3.

Embodiment 9

The method of any one of embodiments 1-7, wherein the quantification standard is an isotopically-enriched peptide of TABLE 6 or TABLE 7.

Embodiment 10

The method of any one of embodiments 1-9, wherein the quantifying is performed by mass spectrometry.

Embodiment 11

The method of any one of embodiments 1-10, wherein the quantifying is performed by parallel reaction monitoring mass spectrometry.

Embodiment 12

The method of any one of embodiments 1-9, wherein the quantifying is performed by contacting the test sample with a phospho-specific antibody.

Embodiment 13

The method of any one of embodiments 1-12, wherein the quantifying comprises detecting a ratio of the wild type phosphopeptide amount to an amount of a non-phosphorylated form of the wild type peptide.

Embodiment 14

The method of embodiment 13, wherein the ratio of the amount of the wild type phosphopeptide to the amount of the non-phosphorylated form of the wild type peptide is greater than a corresponding ratio obtained from a control sample obtained from a test subject that has pulmonary arterial hypertension.

Embodiment 15

The method of embodiment 13, wherein the ratio of the amount of the wild type phosphopeptide to the amount of the non-phosphorylated form of the wild type peptide is less than a corresponding ratio obtained from a control sample obtained from a test subject that has pulmonary arterial hypertension.

Embodiment 16

The method of embodiment 13, wherein the ratio of the amount of the wild type phosphopeptide to the amount of the non-phosphorylated form of the wild type peptide is greater than a corresponding ratio obtained from a test subject that does not have pulmonary arterial hypertension.

Embodiment 17

The method of embodiment 13, wherein the ratio of the amount of the wild type phosphopeptide to the amount of the non-phosphorylated form of the wild type peptide is less than a corresponding ratio obtained from a test subject that does not have pulmonary arterial hypertension.

Embodiment 18

A chemical aliquot comprising a sample of a phosphopeptide, wherein at least 1% of the sample of the phosphopeptide consists of molecules that have an amino acid residue that has at least two ¹³C nuclei, wherein the sample contains at least 1 pg of the phosphopeptide, wherein the phosphopeptide has at least 90% sequence identity to any compound of TABLE 2 or TABLE 3.

Embodiment 19

The chemical aliquot of embodiment 18, wherein at least 10% of the sample of the phosphopeptide consists of molecules that have the amino acid residue that has at least two ¹³C nuclei.

Embodiment 20

The chemical aliquot of any one of embodiments 18-19, wherein at least 50% of the sample of the phosphopeptide consists of molecules that have the amino acid residue that has at least two ¹³C nuclei.

Embodiment 21

The chemical aliquot of any one of embodiments 18-20, wherein the amino acid residue that has at least two ¹³C nuclei has at least three ¹³C nuclei.

Embodiment 22

The chemical aliquot of any one of embodiments 18-20, wherein the amino acid residue that has at least two ¹³C nuclei has six ¹³C nuclei.

Embodiment 23

The chemical aliquot of any one of embodiments 18-22, wherein the amino acid residue that has at least two ¹³C nuclei has at least two ¹⁵N nuclei.

Embodiment 24

The chemical aliquot of any one of embodiments 18-23, wherein the amino acid that has at least two ¹³C nuclei residue is lysine.

Embodiment 25

The chemical aliquot of any one of embodiments 18-23, wherein the amino acid residue that has at least two ¹³C nuclei is arginine.

Embodiment 26

A kit comprising: a) a chemical aliquot comprising a sample of a phosphopeptide, wherein at least 1% of the sample of the phosphopeptide consists of molecules that have an amino acid residue that has at least two ¹³C nuclei, wherein the sample contains at least 1 pg of the phosphopeptide, wherein the phosphopeptide has at least 90% sequence identity to any compound of any of TABLE 2 or TABLE 3; and b) an additional aliquot comprising a sample of the phosphopeptide that has nuclei in a natural abundance of isotopes.

Embodiment 27

A method comprising: a) obtaining a test sample of tissue from a subject; b) assaying the test sample to quantify in the test sample a phosphorylation level of a peptide; c) comparing the phosphorylation level of the peptide to a phosphorylation level of a corresponding peptide in a control sample; d) based on the comparing the phosphorylation level of the peptide to the phosphorylation level of the corresponding peptide in the control sample, determining whether the subject suffers from a pulmonary condition; and e) based on the determining whether the subject suffers from the pulmonary condition, administering to the subject a pharmaceutical compound for treatment of the pulmonary condition.

Embodiment 28

The method of embodiment 27, wherein the phosphorylation level of the peptide in the test sample is greater than the phosphorylation level of the corresponding peptide in the control sample.

Embodiment 29

The method of embodiment 27, wherein the phosphorylation level of the peptide in the test sample is lesser than the phosphorylation level of the corresponding peptide in the control sample.

Embodiment 30

The method of any one of embodiments 27-29, wherein the pharmaceutical compound is a kinase inhibitor.

Embodiment 31

The method of any one of embodiments 27-30, wherein the pharmaceutical compound is of the formula:

or a pharmaceutically-acceptable salt thereof.

Embodiment 32

The method of any one of embodiments 27-31, wherein the pulmonary condition is pulmonary arterial hypertension.

Embodiment 33

The method of any one of embodiments 27-32, wherein the control sample is obtained from a subject with pulmonary arterial hypertension.

Embodiment 34

The method of any one of embodiments 27-32, wherein the control sample is obtained from a subject free of pulmonary arterial hypertension.

Embodiment 35

The method of any one of embodiments 27-34, wherein the quantification of the level of the peptide in the test sample is saved to a computer system, wherein the computer system stores the phosphorylation level of the corresponding peptide in the control sample, wherein a processor of the computer system performs the comparing.

Embodiment 36

The method of any one of embodiments 27-35, wherein the peptide in the test sample and the corresponding peptide in the control sample have identical amino acid sequences. 

What is claimed is:
 1. A method comprising: a) adding to a sample of a protein extracted from a buffy coat an amount of a quantification standard to provide a test sample; and b) assaying the test sample to quantify in the test sample a wild type phosphopeptide of the protein extracted from the buffy coat, wherein the quantifying is based on the amount of the quantification standard, wherein the quantification standard is a form of the phosphopeptide that is isotopically enriched to a non-natural abundance of an isotope.
 2. The method of claim 1, further comprising: i) obtaining a tissue sample from a human subject, wherein the tissue sample contains the buffy coat; and ii) isolating the protein from the tissue sample to provide the sample of the protein.
 3. The method of claim 2, further comprising digesting the sample of protein prior to adding the amount of the quantification standard.
 4. The method of claim 2, wherein the human subject has pulmonary hypertension.
 5. The method of claim 2, wherein the human subject has pulmonary arterial hypertension.
 6. The method of claim 4, wherein the pulmonary hypertension is idiopathic pulmonary hypertension.
 7. The method of claim 4, wherein the pulmonary hypertension is pulmonary hypertension associated with systemic sclerosis.
 8. The method of claim 1, wherein the quantification standard is an isotopically-enriched peptide of TABLE 2 or TABLE
 3. 9. The method of claim 1, wherein the quantification standard is an isotopically-enriched peptide of TABLE 6 or TABLE
 7. 10. The method of claim 1, wherein the quantifying is performed by mass spectrometry.
 11. The method of claim 1, wherein the quantifying is performed by parallel reaction monitoring mass spectrometry.
 12. The method of claim 1, wherein the quantifying is performed by contacting the test sample with a phospho-specific antibody.
 13. The method of claim 1, wherein the quantifying comprises detecting a ratio of the wild type phosphopeptide amount to an amount of a non-phosphorylated form of the wild type peptide.
 14. The method of claim 13, wherein the ratio of the amount of the wild type phosphopeptide to the amount of the non-phosphorylated form of the wild type peptide is greater than a corresponding ratio obtained from a control sample obtained from a test subject that has pulmonary arterial hypertension.
 15. The method of claim 13, wherein the ratio of the amount of the wild type phosphopeptide to the amount of the non-phosphorylated form of the wild type peptide is less than a corresponding ratio obtained from a control sample obtained from a test subject that has pulmonary arterial hypertension.
 16. The method of claim 13, wherein the ratio of the amount of the wild type phosphopeptide to the amount of the non-phosphorylated form of the wild type peptide is greater than a corresponding ratio obtained from a test subject that does not have pulmonary arterial hypertension.
 17. The method of claim 13, wherein the ratio of the amount of the wild type phosphopeptide to the amount of the non-phosphorylated form of the wild type peptide is less than a corresponding ratio obtained from a test subject that does not have pulmonary arterial hypertension.
 18. A chemical aliquot comprising a sample of a phosphopeptide, wherein at least 1% of the sample of the phosphopeptide consists of molecules that have an amino acid residue that has at least two ¹³C nuclei, wherein the sample contains at least 1 pg of the phosphopeptide, wherein the phosphopeptide has at least 90% sequence identity to any compound of TABLE 2 or TABLE
 3. 19. The chemical aliquot of claim 18, wherein at least 10% of the sample of the phosphopeptide consists of molecules that have the amino acid residue that has at least two ¹³C nuclei.
 20. The chemical aliquot of claim 18, wherein at least 50% of the sample of the phosphopeptide consists of molecules that have the amino acid residue that has at least two ¹³C nuclei.
 21. The chemical aliquot of claim 18, wherein the amino acid residue that has at least two ¹³C nuclei has at least three ¹³C nuclei.
 22. The chemical aliquot of claim 18, wherein the amino acid residue that has at least two ¹³C nuclei has six ¹³C nuclei.
 23. The chemical aliquot of claim 18, wherein the amino acid residue that has at least two ¹³C nuclei has at least two ¹⁵N nuclei.
 24. The chemical aliquot of claim 18, wherein the amino acid residue that has at least two ¹³C nuclei is lysine.
 25. The chemical aliquot of claim 18, wherein the amino acid residue that has at least two ¹³C nuclei is arginine.
 26. A kit comprising: a) a chemical aliquot comprising a sample of a phosphopeptide, wherein at least 1% of the sample of the phosphopeptide consists of molecules that have an amino acid residue that has at least two ¹³C nuclei, wherein the sample contains at least 1 pg of the phosphopeptide, wherein the phosphopeptide has at least 90% sequence identity to any compound of any of TABLE 2 or TABLE 3; and b) an additional aliquot comprising a sample of the phosphopeptide that has nuclei in a natural abundance of isotopes. 